Laryngology Seminar
Paradoxical vocal cord movement
R3 許惇彥 2003/08/27

Definition
Adduction of vocal cord(s) while inspiration +/- expiration

Synonym
Paradoxical vocal cord dysfunction, Functional airway obstruction,
Functional stridor, Episodic paroxysmal laryngospasm (EPL),
Munchausen’s stridor, Factitious asthma, steroid-resistent asthma,
Irritable laryngeal syndrome

Symptoms

(1) Dyspnea (esp. difficulty in getting air in than out), aphonia or
dysphonia
(2) Throat tightness, grabbing throat
(3) Dramatically abruptly begin and resolve*
(4) Up to 72 hours every time
Signs
(1) Stridor (correlated poorly with severity of respiratory
distress*)
(2) ABG: normocapnic, normal Alveolar-arterial gradient*
(3) CXR: no hyperinflation, no peribronchial thickening*
(4) Negative result in asthma provocation test*
(5) Normal serum eosinophile counts*
(6) Inability to reproduce the abnormal laryngeal motion
consciously voluntarily
(7) Failure of clinical response to standard bronchodilator and
steroid therapy +/- iatrogenic Cushing’s syndrome
* Different from asthma

History
(1) 1842, Dunglison - disorders of laryngeal muscle brought on by
hysteria
(2) 1869, Mackenzie - first visualized vocal cord paradoxical
movement
(3) 1902, William Osler - laryngeal muscle spasms during
inspiration and times of great stress
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(4) 1974, Patterson - Munchausen’s stridor, factitious asthma
(5) 1978, Rogers and Stell – paradoxical movement of vocal cords
as a cause of stridor
(6) 1982, Kellman & Leopold – Laryngeal stimulation eq. URI may
direct patients attention to the larynx
(7) 1983, Christopher – conversion disorder
(8) 1987, Martin
(9) 1992, Newman & Dubester
(10) 1997, Morrison – irritable laryngeal syndrome
 Demography
(1) Young female (18~33 y-o)
(2) Overweight
(3) Medical or paramedical professional background
(4) Psycho-social stress or problem (50%~85%)
(5) Preceded by acute upper airway infection
(6) Predominantly attacks during the daytime
(7) 1994, National Jewish Center - Of refractory asthma, 10%
had PVCM only and 30% had PVCM with coexistent asthma
(8) Diagnosis achieved ~5 years after initial attack with 5~10
times emergent department visiting or hospital admission

Diagnosis
* Mistaken for anaphylaxis, angioedema, or status asthmaticus *
(1) Typical laryngoscopic findings (2) Spirometry: truncated
(+/- posterior chink)
inspiratory pattern
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- interarytenoid edema or pachydermia, posteriorly displaced

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epiglottis, anterior-posterior constriction of supraglottis
(3) Fluorosocpy
(4) Provocation test by chemical irritant or exercise
Cause and classification
Treatment
(1) Make patient distracted
(2) Panting, sniffle position, breathing holding
(3) Psychotherapy
(4) Speech therapy
(5) O2 supplement or Heliox (20% oxygen, 80% helium)
(6) Benzodiazepam (Midazolam 0.5~1.0 mg intravenously)
(7) Botulinum toxin intralaryngeal injection
(8) Antireflux therapy
(9) Antiallergy agents
(10) Establish airway if indicated!!
(11) Asthma treatment if existed!!

Long term prognosis
Tracheostomy may be necessary !?
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
Reference
1. Munchausen stridor: non-organic laryngeal obstruction Clinical Allergy 1974;4:307-10
2. Paradoxical movement of the vocal cords as a cause of stridor J Laryngol Otol
1978;92:157-8
3. Cough and paradoxical vocal fold motion Otolaryngol Head Neck Surg 2002;127:501-11
4. Airway fluoroscopic diagnosis of vocal cord dysfunction syndrome Ann Allergy Asthma
Immunol 1997;78:586-8
5. Paradoxical vocal cord motion: an important cause of stridor Laryngoscope
1982;92:58-60
6. Fluoroscopic Diagnosis of Laryngeal Asthma (Paradoxical Vocal Cord Motion) AJR
1995;165:1229-31
7. Post-anesthesia Paradoxical Vocal Cord Motion Successfully Treated with Midazolam
Anesthesiology 1998;89:517-9
8. Vocal Cord Dysfunction in a Child with Asthma J Asthma 1991;28:141-5
9. Vocal Cord Dysfunction Masquerading as Exercise-Induced Asthma Am J Respir Crit Care
Med 1996;153:942-7
10. Acute Respiratory Distress Due to Vocal Cord Dysfunction in Cystic Fibrosis J Asthma
1991;28:443-6
11. Paradoxical Vocal Cord Dysfunction in Juveniles Arch Otyolaryngol Head Neck Surg
2001;126:29-34
12. Paradoxical vocal cord dysfunction in an infant with stridor and gastroesophageal reflux
Int J Pediatr Otolaryngolaryngol 1996;34:149-51
13. Paradoxical vocal cord motion in a child presenting with cyanosis and respiratory failure
Pediatr Crit Care Med 2002;3:185-6
14. Effects of benzodiazepines on laryngeal reflexes Anaesthesia 1987;42:808-14
15. Three Cases of Paradoxical Vocal Cord Adduction Followed Up Over a 10-Year Peroid
Chest 1993;104:678-80
16. Clinical Features of Vocal Cord Dysfunction J Respir Crit Med 1995;152:1382-6
17. A classification Scheme for Paradoxical Vocal Cord Motion Laryngoscope
1997;107:1429-35
18. VOCAL-CORD DYSFUNCTION PRESENTING AS ASTHMA N Eng J Med 1983;308:1566-70
19. Factitious Asthma JAMA 1982;248:2878-81
20. The irritable larynx syndrome J Voice 1999;13:447-55
21. Use of Botulinum Toxin Type A to Avoid Tracheal Intubation or Tracheostomy in Severe
Paradoxical Vocal Cord Movement Chest 2000;118:874-6
22. Irritant-Associated Vocal Cord Dysfunction J Occup Environ Med 1998;40:136-43
23. Stridor: Differentiation from Asthma or Upper Airway Noise Am Rev Respir Dis
1989;139:1407-9
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